Millions of Seniors Facing Medicare 'Doughnut Hole'

Millions of older Americans are confronting a temporary break in their Medicare drug coverage this month that will require them to pay the full cost of their prescriptions or face the painful prospect of going without.

This is the "doughnut hole" in the new Medicare drug benefit that began in January, and advocates for seniors say there is nothing sweet about it. Some seniors knew nothing of the coverage gap until they were hit with a bigger drug bill, advocates say.

"Virtually everyone who calls to say they've been denied coverage, they're shocked," said Robert M. Hayes, president of the Medicare Rights Center, a nonprofit that helps seniors navigate Medicare. "Trying to explain that this is the way the program was created by Congress angers folks who think it makes no sense. Many people feel blindsided."

The coverage gap was one of the most contentious elements of the 2003 legislation that created the new benefit. It ends federal payments for a person's drug purchases once an annual spending limit is reached, resuming them only after the beneficiary has spent thousands of dollars out of pocket.

Proponents saw the unusual setup as a way to provide some help to all beneficiaries, and substantial help to those with catastrophic drug costs, and yet not break the bank in a federal program that is expected to cost hundreds of billions of dollars over the next decade.

Nine months into the program, as more and more seniors reach the threshold that puts them in the gap, many see it as a headache -- or worse.

Frances Acanfora, 65, had been paying $58 for a three-month supply of her five medications. But this month the retired school lunchroom aide learned that her next bill would be $1,294. She had entered the doughnut hole.

"It's not my fault that I take this medicine," the Brooklyn resident said. "I've got to take it. And they make a limit. That's not fair."

After talking to her doctor, Acanfora decided to temporarily stop taking a drug as part of her treatment for breast cancer. She hopes to obtain some free samples of eye drops for her glaucoma. Three other medicines -- for high cholesterol, diabetes and osteoporosis -- cost $506.62, which Acanfora put on her credit card.

"I pay a little bit at a time," she said. "What am I going to do? I need it. . . . Sometimes, just to think about it, I cry."

About 3 million of the 23 million Americans who receive the Medicare drug benefit are expected to reach the gap this year, officials said. That is fewer than half the 7 million cited in a 2004 report by the nonprofit Kaiser Family Foundation, which Medicare chief Mark B. McClellan called outdated.

A few more-expensive plans have no doughnut hole, and low-income beneficiaries can receive extra help from Medicare that eliminates the gap. Under the standard plan, however, the government picks up the bulk of drug costs only until the beneficiary and the government together have spent $2,250 for the year. At that point, beneficiaries must pay 100 percent of costs until they have spent a total of $3,600 of their own money. Then the federal subsidy resumes, paying 95 percent of any additional expenses.